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32C-214 (10) 0� l t�� �� �•�� W.Q D� Cj ► CERTIFICATE OF 14ABILITY INSURANCE 8/1,2/201.5 ~ s ly fs is ED A:3 A MA. OF INFORMATION t��ILY AND CONFERS K0 RIGHTS UIsC7N "fFi CERTIFICATE HOLDER, Tl�fs cm, IS � {tI AiRFtt ATNEI.Y"flR NeGATIVELY AIl+ 0, EXTEND OR ALTER THE COVERAGE AFFORDED fS1C +*,iErRT I #"# C3 INSIIRANCIY DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING iNSURIwR(S), AltttlClftZEl3 IENTATf? f' t?Ot10EFt,AfD TNE-CERtFICATg t'IWI.Dt, i I TAt1T -Wow r�fcl3stel Its a IS art ADDITIONAL tNSURED,.#*posiicy(Iss)must be ondorsed. If SUBROGATION IS WAIVED,*Aect to lrtti ItIIIE roc ditl6hi of the Ists tosy,car a po ides may requlna ain endorsement. A statement on this certificate doses not confer rights to the c. xtlficastd III ftlliu such endome men s. I c DO 3tary 'Woodard Aai a t'X#04 a acre Agency Inc Ne (423)253-5555 I t+133256-8354 20 Gat aboux.ja'Rd,i ruxoodsrd$nath mx3 qe loi.las.ceases P`0. Abs t 413 INa111! s A�WRCsIrt swer�Ara� NP CC• s t: AtA 01002 .; IAT$ RER A:flcn ec i cu t`,.Unde rwr ite rs Inn Is11 Ii not is NeIthanial Bruursema DSA MIMRER c, Brourge a Ox lder rNStlRax n. 57 5b th �'e,l eyr Road INSURER E a Pia HK 01002 tNS$IRE3l Cf f IA E►iT1FI Tex NLIIYIf3ERtCxr14A2t#01599 REVISION NURkI3ER. T#NS'IS.TO CE#tW THAT THE POLICIES OF $URAf4CE USTED SELOVW HAVE BEEN ISSUED TO THE INSURED WMED ABOVE FOR THE F'd 1�1'PERIOD MOICATE6 ,f�40"I'WITHSTANDING ANY REQUIR�gtI NT.TERM OR CONDIl$0N OF ANY CONTRACT OR OTHER DOCUMENT VATH RESPECT TO:WHICH THIS OF.R�'IFiCiATE deIJ4Y'P7E ISSUED OR MAY PI:RT`AMN THE 040RANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, E CAL IC}luis AND ONQITIC3I OF SUCH PCJLIC..IES.LIMITS SHC3VW MAY 14WE 95EN REDUCED BY PAID CLAIMS, THE OF mock t11Ci» IdU R Y Y � CCU RRENCE $ 300 0 t OF* .. X COMAMPCIAL GENERAL LIABILITY PREMISES 100,000 111 0LA0A4AADE OCCUR PP'8180545 12tm12Q s f28f E116 MEDEXP An nna x $ 5,014 PERSONAL aAVV;NJURY s 300,00 GENERAL A00REGATE s ....,.. S00,000 IR'1,,a0,GRf LIMIT, Ft�s KIIt, PRODUCTS-COMFIOP AGG S SOLI;000 = $ lt9JT�ItrE LTA .rTY N A14Y AiJTtt BODILY INJURY{Par parsnnf ALj;D PSCHEDULIED BODILY INJURY(Pw 0060 a) $ V011NED PROPERTY DAMAGE ___.. $ OCCUR EACH OcCURRENCE S CLAWS-MADE AGGREGATE $ t rF EAT N .' YJG ST#Tv l3TII- JI�t oYlracJT ANY Pft YIPI ;( I R/A P.L.EACH ACCIDENT S fi3F)K ft A CCLiJ GX4 (., I E.L.DISEASE-EA EMPLOYEE EMOTOOMW. kas sv E:L DISEASE-POLICY LIMIT *F=;qPTwN Op opotAno tS 1 LOCATIONS I vt"CLM IA*ach ACORD 101,AddManai Remarks 4chaduW,N O*Ora*P*C:*Is raquim4l CERTIFIC9?T HOLDER CANCELLATION l'jl'nne r3dwards8y'ahot>.CCIIt S14OULD ANY Of THE A13C1VE fRFF E�J POLICIES BE CANCELLED BEFORE THE E3CPIRATtON QATE ttt3TIGB 1aHLL BE DELIVERED IN AGC t�ANCE VYITH THE . I:3IO S. L��,f��.rsardls 35 1��s3.� lse Beset ,auT11 ra PRast:NTRTtu1w 1�Torth"lpton, fib. 01060 M& Moods ACORD 25(20M OS) a 1985-2010 ACORD.Ct�RPt3RATfCi�t: All rights reserved. WS026watxlsl:at The ACORD name and tugo are registered marks of ACORD I A.. U1P'�d�I N•� C�E'S7 N��`���C'i.r� e� 51s�-'� IT Zi �d 1-°re`ll 1 � City of Northampton 212 Main Street, Northampton, MA. 01 060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. Address of the work: D '12 S1 The debris will be transported by: The debris will be received by: V��� c 1 '- Building permit number: Name of Permit Applicant �Aoo-x Z d� (A- /_1 Date Signature of Permit Applicant City of Northampton /� r'• " r' Massachusetts DEPARTMENT OF BUILDING INSPECTIONS * 212 Main Street • Municipal Building s° Northampton, MA 01060 INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two- year period shall not be considered a home owner." The building department for the City of Northampton wants any person(s)who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation/footings (before backfill) sonotube holes (before pour), a rough building inspection (before work is concealed), insulation inspection (if required) and a final building inspection. The building department requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will be responsible to make sure that the trades hired secure their proper permits in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made I understand the above. (Home owner/resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street r Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Narrle (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. E] I am a general contractor and I 6 ❑New construction (full and/or part-time).* have hired the sub-contractors 2. Vemployees I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance. required.] 5. We are:a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. tHo meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lie. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. lIdo ereb y fy under t ains andpenalties ofperjury that the information provided above is true and correct. ure: Date: Phone#: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Su ervisor: Not Applicable £ Name of License Holder:. 0.H (LiuY I,, `5__ li`00 License Number Addres Expiration Date 326 qqV � Signature Telephone 9.Re ere imp rov ent Cont ract or,' _` ___... '._�._,..: ..... ___-.. Not Applicable £, rc4w L, ,, ��� rV,5 (l 7L7 C moC pane Name �� d ' t / p02 Registrat n Number Address Expiration D to Telephone y i3 3ZG q q3 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c:152,§25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... £ No...... £ 11 Hone Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner:Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s) you hire to perform work for you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature, i i SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House Addition ❑ Replacement Windows Alterations} Roofing Or Doors F1 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[lam] Other[0] Brief Description of Proposed ] -� Work: C. �� tJ Z� c�r�'S-5 Gam- nr G"�'�t'1 � r.�°) ()r Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa If Newhouse andor adtlltlon to exisflnq hous>n4 cornR�efe>�le followlnct: a. Use of building :One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d, Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No. 1. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO 13E COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, Winne � u34 rd.S as Owner of the subject property hereby authorize 1YQ )t/ien i e/ Z/ L)a( Y S P/f)a- to act on my behalf, in all matters relative to work authorized by this building permit application. Signatu4of Owner Date l ��1 r )' PNOk as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed der h pains and enalties of perjury. 0-ld Print NVfiely �u Signature of Owner/Agent Date I Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front [ t Side L:' [ R: L! ! R:=` , �'t Rear Building Height „( Bldg.Square Footage 1 Open Space Footage i _ % ! (Lot area minus bldg&paved parking) #of Parking Spaces L---—j Fill: (I E I; (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DONT KNOW O YES Q IF YES, date issued:j _-1 IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW Q YES Q J IF YES: enter Boak Page and/or Document#; i B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained Q , Date Issued: C. Do any signs exist on the property? YES 0 NO O IF YES, describe size, type and location: f D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO Q IF YES, describe size, type and location: _ E. WII the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES Q NO Q IF YES,then a Northampton Storm Water Management Permit from the DPW is required. i i i �,:,Aeparfinert use only r ,r � zl ( I of Northampton Status,ofPerrntt ( I t of Department C�rr�cut/Drl�ce�ray Perrrtt# 2'�2 Main Street SewerlSeptieAuailabllrty , AUG ( � ?,()lb Room 100 Vlfaterlfal�Ava�la6ihty U u` NArtha pton, MA 01060 ME* i al Plans -.,,;p�iahe 4� 7 1240 Fax 413-587-1272 PIo�/Slte Plans 1 � � Y '� ''t x i EleCtYl� ` _G\ 1 ,i'J OtherSpecify°r .. i5 y`, APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This sectiorr to be com lefetl b office R Y 1.1 Property Address: C,� s r U' 1G'Y l�j�'.�3i'� I 0 //� o)d(p© :Zone Overlay District :Elm St_Distncf. . SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT: 2.1 Owner of Record: an C- Name(Print) �� FY�S Current Mail' , /�a ��J i / ynnt° ct� Telephone l5 /�� Signature (41 3) V6 2.2 Authorized Agent: 1'�IolAt t Ct% ` Q M 3 S Name(Pri Current Mailing Address: Signature Telephone SECTION 3 -ESTIMATED CONSTRUCTION COSTS. . Item Estimated Cost(Dollars)to be Official Use Only completed b ermit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost.c Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Tota1=0 +2+3+4+5) Check Number This Section For Official`Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector`of Buildings Date File#BP-2016-0190 APPLICANT/CONTACT PERSON NATHANIEL BRUURSEMA ADDRESS/PHONE 57 SOUTH VALLEY RD PELHAM01002(413)326-4943 PROPERTY LOCATION 35 HOLYOKE ST MAP 32C PARCEL 214 001 ZONE URC(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid - Buildin Permit Filled out Fee Paid Typeof Construction: CONSTRUCT EGRESS RAMP W/4'LANDING ON FRONT PORCH New Construction Non Structural interior renovations Addition to Existine Accessory Structure Building,Plans Included: Owner/Statement or License 100441 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO AKATION PRESENTED: Approved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management Si of uil ' g icial Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. * Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning& Development for more information. 35 HOLYOKE ST BP-2016-0190 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32C-214 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit# BP-2016-0190 Project# JS-2016-000325 Est. Cost: $500.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: NATHANIEL BRUURSEMA 100441 Lot Size(sq. ft.): 3789.72 Owner: EDWARDS LYNNE K Zoning. URC(100)/ Applicant. NATHANIEL BRUURSEMA AT. 35 HOLYOKE ST Applicant Address: Phone: Insurance: 57 SOUTH VALLEY RD (413) 326-4943 PELHAMMA01002 ISSUED ON.811712015 0:00:00 TO PERFORM THE FOLLOWING WORK:CONSTRUCT EGRESS RAMP W/4' LANDING ON FRONT PORCH POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 8/17/2015 0:00:00 $65.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner